Weighing the Pros and Cons of Statins

Are you among the 73 million Americans with cholesterol levels that current guidelines suggest should be lowered by taking a statin for the sake of your cardiovascular well-being? Have you and your doctor discussed the pros and cons of statin therapy and whether it is appropriate for your circumstances?

If not, now is the time to do so. Too often, patients are given a prescription with little or no discussion of what the drug can mean for their health, and that affects their willingness to take it or stay on it.

Dr. Seth Martin, a preventive cardiologist at Johns Hopkins Hospital, strongly recommends that taking a statin be a fact-based, collaborative and personalized decision between doctor and patient, following one or more discussions of the individual’s medical and personal concerns.

Maybe you’ve already been prescribed a statin and are among the 45 percent of such patients who never took the medication or who abandoned it within six months, perhaps because you’ve heard scary stories about possible side effects.

If so, I’m not surprised. Bad news about drugs travels fast, and reports of side effects are often exaggerated and rarely presented in a way that is meaningful to those who might be affected. (The same is true for a drug’s benefits, which are often described with statistics that mean little to the average person.) Misinformation, or misinterpretation of factual information, can result in what doctors call the “nocebo” effect — the experience of an anticipated side effect even when the patient is given a dummy pill.

A personal example: After being on a statin for nearly two decades to lower a genetically influenced high cholesterol level, I recently decided to take a drug holiday after reading about how the medication can affect muscle metabolism and sometimes cause muscle pain and damage.

Was the statin, I wondered, and not my age, the reason I was finding it harder to cycle, walk and swim? Could this otherwise valuable medication contribute to my back pain?

“A person’s expectation of the effects of statins can result in the experience of symptoms and relating those symptoms to the drug,” Dr. Martin explained. Thus, I may feel better without the statin even if the drug is not responsible for my symptoms. Regardless of the outcome, I expect to return to the statin lest I succumb to a “premature” heart attack, as my father and grandfather did.

As an international team of researchers pointed out in The Lancet in 2016, “exaggerated claims about side-effect rates with statin therapy may be responsible for its underuse among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.”

Unlike medications prescribed to treat a symptom or illness, statins are often given to healthy people to prevent a potentially devastating health problem, and the drug must be taken indefinitely to do the most good. Nearly half of Americans with cholesterol levels that put them at high risk of a heart attack or stroke are not taking medication to reduce that risk, according to the Centers for Disease Control and Prevention. Under current guidelines, among people 60 and older, 87 percent of men and 54 percent of women not already taking a statin would be considered eligible for treatment.

There is no question that statins can protect the health of people who have already had a heart attack or stroke (or even angina) and thus face a significant risk of a recurrence that could prove fatal. But many people — especially those who are uncomfortable taking drugs for any reason — resist taking a daily statin if they have no history or symptoms of cardiovascular disease, only a risk of developing them, especially since it has not yet been proven that the drugs help such people live longer.

Furthermore, people correctly regard “risk” as a possibility, not a probability, and vary in the degree of risk they are willing to tolerate. One chance in 100 may be acceptable to one person, while another may regard one chance in 1,000 as too risky.

Doctors define cardiovascular risk as a percentage chance of a heart attack or stroke occurring within the next 10 years based on the presence of well-established risk factors: high cholesterol, high blood pressure, smoking, diabetes, age, gender and race (and, in some cases, family history). You can determine your own risk using the calculator developed by the American College of Cardiology and American Heart Association at cvriskcalculator.com.

If your calculated risk is 7.5 percent or higher, your doctor is likely to suggest you consider taking a statin, although a relatively high cholesterol level may not result in such a recommendation if you have no other heart risk factors. The risk score is meant “to start a conversation, not to write a prescription,” according to Dr. Don Lloyd-Jones, professor of preventive medicine at Northwestern University Feinberg School of Medicine and a spokesman for the heart association.

Let’s say your risk is 19 percent. That means among 100 people with similar risk factors, 19 are likely to have a heart attack or stroke within the next decade. Is that a risk you’re willing to take? Or would you rather reduce your risk by a third by taking a statin? Only you can make that determination, and it should be based on a full understanding of the known benefits and risks of statins, not something you may have heard from a friend or read online.

The current labeling on statin prescriptions doesn’t help matters. In 2012, the Food and Drug Administration ruled that the warnings should include several reversible side effects: confusion and memory loss, liver problems, increases in blood sugar and muscle weakness, as well as interactions with certain other medications.

But the label doesn’t state how rarely such problems occur, and reading the list of possibilities could scare off some people, especially those already timid about taking a lifelong drug.

The longer someone is on statin therapy, the greater the reduction in the risk of a cardiovascular event. The drug works primarily by lowering blood levels of harmful LDL cholesterol that can otherwise collect inside arteries that feed the heart and brain. It also helps to stabilize existing plaque, lowering the chances that a chunk will break loose and trigger a heart attack or stroke. There are also several different statins available that vary in potency and side effects, and all leading brands are now available as inexpensive generics.